Transcript
mmateri: Hi, I'm Josh McDonald.
Tristany: And I'm Tristany Barry, and this is Hand Therapy Academy.
mmateri: So we've got another one of these where Trissany is asking some questions that hopefully we can all benefit from a little bit. Trissany, go ahead, what's our next question?
Tristany: um When you see it, how do you kind of identify CRPS when you might have a patient that's kind of on the edge? What are kind of the telltale signs?
mmateri: Um, so that's a good question. A lot of times we are the first line of, of identifiers for that. If a patient has a distal radius fracture, maybe they fall into that standard demographic. We're not exclusive that demographic, but they're certainly higher on our radar. Someone who has maybe, um, they're in that middle -aged female demographic, uh, trauma, the distal, uh, extremity, maybe just a radius fracture, maybe a metacarpal fracture.
mmateri: sometimes flanges, but not as often. um We're a little bit more on guard for that. We're watching for some some early indicators. If you have a chance, we highly encourage everyone go find the Budapest scale, um like Budapest the location. um And there are specific criteria and it says you need to have at least one sign in two or more categories, no other diagnoses, but it gives us kind of almost like a DSM -4 kind of criteria for identifying this.
mmateri: um There's sensory responses, vasomotos, pseudomotor, and mototropic. And we're looking for stiffness. We're looking for increased pain. We're looking for skin temperature or texture differences. We're looking for a kind of edema that's different, right? Like we know swelling and there's like pitting swelling. Then there's what's called like brawny edema. And that brawny edema is like a denseness to it, especially early on, like at the two to four week mark.
mmateri: like this is not normal edema the fingers almost become this tapered conical shape um and they get very pointed to the tip because the edema is all very proximal um we're looking for early on you're not likely to see the dark hair growth because that takes time to develop um but we're looking for sweat like clammy hand just on that one side those kinds of things But a lot of times they'll have like a distal radius fracture. They go get the surgery that the night or the day after they're injured, maybe a couple of days later, they go to the doctor to one week follow up. But all of these signs can take some time to present themselves and declare themselves. So it may be by the time they come to us for cast off and splinting and starting early active protocol, that that's when we start to see like, hey, they are like abnormally stiff and they are super sensitive to pain.
mmateri: One of the things I like, I like to do in one of our the clinics where we have access to it is I like to watch them walk in from the car or the waiting room and what's their hand position. If they're holding it up in that guarded position and they're on high alert with it, that's just one of those things that kind of points towards that. Like let's just keep it on our radar a little bit.
Tristany: Sure, and then once you kind of have those signs, what do you do next?
mmateri: So if they're on those early indicators, I'm not jumping to the, okay, they've got CRPS. but Surgeons oftentimes will look at someone with, well, your pain is more sensitive than it should be. So it's probably CRPS. I want to go to the Budapest scale and have multiple indicators from different categories because some of our patients have nerve injuries or neuromas or other things that flare up pain.
mmateri: And it kind of becomes like the scarlet letter for people when I stamp them too early with that. And I go mentioning it to a doctor or certainly putting in their chart. um I'm not supposed to diagnose someone. But if I start to give those indicators, that then affects their access to care later because no one wants to touch that and flare that up for a tinolysis or hardware removal or carpal tunnel release, all these things that may be necessary down the road. So I'm hesitant to jump down that diagnostic pathway too early.
mmateri: But there are some things I'll do early on to work on minimizing impact, sometimes preventing it from becoming full fledged CRPS. We can do a lot with those patients early on in the first two to six weeks to keep those side effects, those, those Budapest indicators from flaring up into full blown CRPS.
Tristany: And how long do you kind of expect to see these patients and treat them?
mmateri: So that kind of depends on if it becomes that full -blown CRPS. We've done another um podcast and we can touch base a little bit here on specifically what some of those things are, some of those early indicator things. um We can touch base on those too in a couple minutes. But I expect someone who's on that trajectory to be a little longer. I'd like a standard healing well, not a ton of stiffness kind of distal radius fracture, metacarpal fracture to be done around week 12, give or take, maybe week eight,
mmateri: maybe week 14 or so, but then they can move on and do normal stuff and they're back to normal life and they're at that 90 % ready for discharge. 90 % range of motion, strength, all that stuff, ready for discharge. I expect someone who's got those indicators, that's going to delay how early I can start more direct passive range of motion, more direct strength stuff. um They're not using their hand as functionally at home, and that delays progression. So I know that I'm probably gonna tack on in six or eight weeks, give or take, onto the back end of things because everything is a slower progression. If they come out of it well, because we caught it early, maybe not, but I expect it to be that much longer. If it turns into like a full -blown, this patient has CRPS,
mmateri: then it could be six to nine months of managing pain and and trying to get as much function as possible with the limitation of MCP stiffness and edema and increased pain and trying to dial down all of that sympathetic nervous system response.
mmateri: Yeah.
Tristany: Okay. And what is your approach to treatment when you're seeing them for a kind of a longer period of time?
mmateri: ah yeah So early on I'll do a lot of that stress loading and maybe some graded motor imagery stuff. I really like the stress loading concepts we have from Walmart like these scrub brushes that are like 9 inches long and 4 inches wide. And they have a good handle so you don't have to have wrist extension. They have a decent handle. And I have them push into the table and compress those bristles. It's like the old school dystrophile thing where you press and it gives you a little beep and a light lighting up. It's just a little more functional looking version of it. I'll do it on a wall. I'll do it on the tabletop. Maybe if they're short, I have to put them on a box to stand on a little step so they can reach the table because they want that arm and extension. I may give them traction loading, stress loading, where they're walking around with
mmateri: just a we have these little coin banks that we use for coin activities or a one pound dumbbell or something in that hand to activate finger flexion or even a wrist weight around their wrist if they don't have finger flexion enough just to give some proprioceptive kinesthetic feedback. I feel like that's really effective.
mmateri: and then as much functional task as possible. Those patients who are hesitant to use it, they're on guard. When I give them arbitrary exercises, tendon gliding is great, but I want it to be like, look, you can open 25 containers with that hand, at least helping.
mmateri: picking them up out of the basket and putting lids on and off and that kind of thing. I'm giving them putty so we can cut with a knife and fork. I'm giving them very, very functional tasks so they can see that hand engage. It's not perfect. It doesn't look pretty, but say, look at what this hand can do. And then lots of cueing them on not pushing the threshold. Don't go to that point of pain. No pain, no gain does not apply to them like an arthritis patient.
mmateri: Slow and steady is fine. Let's get you out of this pain cycle and just plowing ahead is not worth it.
Tristany: Sure. And what about the hypersensitivity? What are you doing to kind of address that?
mmateri: So we'll usually give them a sensory kit, which is a fancy name for a bunch of squares cut up. So we'll take five different strapping textures, the loop Velcro, the hook Velcro, maybe some um some of our padding, the edging, a stockinette texture. We throw them in a Ziploc bag, little two by two squares, and we say, I want you to do this kind of all over. That's both for desensitization as it is engagement with this otherwise dissociated body part.
mmateri: So we do that. Stress loading he helps with that sensitivity. We'll do texture play, where we have this big bucket of rice, and it's got a bunch of coins in it. And we'll have them search through. It's both for functional range of motion, sensory, like that stereognosis ability to feel what you can't see because we drew a towel over it, and just that all over washing feel of rice or beans, something to kind of reset that nervous system to say, we don't have to be on high alert. Not everything that touches my hand is going to hurt. And that's a good use, the crossover to use graded motor imagery in that mirror box. So I don't usually pull the mirror box out if they're like, this might turn into CRPS. It's more when we're declaring like we're a little bit further down that pathway. That's when I'll pull out the mirror box and do some stuff with that affected side in the box to kind of trick that nervous system into decreasing the pain sensitivity.
Tristany: Awesome, thank you.
mmateri: Yeah. Yeah, so hopefully that's helpful. It's as much about being aware of it early on and not letting it get too late. Sometimes they don't come to us until it's too late, but if you can identify those stiffness, hypersensitivity, um the sweatiness, that clamminess, a different kind of edema, and you can start addressing that early, you can prevent it from becoming full on CRPS. Even the cognitive training of like put that hand down, you don't need it up so high and and hand them a pen, walk out of here carrying a pen in that hand or a piece of your home program, carry that in that hand, maybe your cell phone, just to get it not dissociated anymore. All right, so hopefully that's helpful. If you have any questions or any feedback, let us know on our email, info at handtherapyacademy dot .com or on our Instagram or Facebook profiles, handtherapyacademy.
